Vaccines and non-citizens: The ‘health for all’ approach

LETTER | The re-emergence of polio in Malaysia after nearly three decades has struck fear among health practitioners and citizens alike. 

Polio is a highly contagious disease that is both crippling and potentially fatal. Although we can’t cure polio, we can prevent it through vaccinations.

Testing on the infant with polio in Tuaran, Sabah has confirmed that the virus is linked to the poliovirus strain currently circulating in the southern Philippines since they declared a polio outbreak in September.

We write this letter to highlight a new angle of the health of non-citizens, especially children. Malaysia has an estimated 3.2 million non-citizens (9.8 percent of the total population). Non-citizens include undocumented migrants, refugees, asylum seekers and stateless people, both adults and children.

Estimating the number of undocumented non-citizen children in Malaysia is difficult, especially in Sabah, where cross-border migration with the Philippines is common. However, the UNHCR estimates that there are 46,340 children below the age of 18, registered with them as refugees and asylum seekers as of October. 

A written response in Parliament in October 2016 declared that there were 290,347 stateless children under 18 years old in Malaysia.

Malaysia is lauded as having achieved Universal Health Coverage by the World Health Organisation through its tax-financed public healthcare system, which provides highly subsidised healthcare to all citizens. However, since 2015, non-citizens have been subjected to considerably higher healthcare charges at public healthcare facilities. The private sector is only partly helping because their charges are equally expensive if not more for non-citizens.

Also, healthcare providers are obliged to report non-citizens without appropriate legal identification documents – like valid passports and work permits – to the police and immigration authorities. In short, financial barriers and the lack of legal documents effectively exclude non-citizens from accessing healthcare in public facilities.

Vaccines are an acknowledged public health “best buy”, being cheap, effective and safe. 

More than 95% of the population needs to be vaccinated to achieve herd immunity. Herd immunity breaks the chain of transmission, indirectly protecting those unable to be vaccinated, who are usually the youngest and most vulnerable. Having pockets of the population who are not immunised or under-immunised puts all children at risk of outbreaks of vaccine-preventable disease, already seen in Malaysia with the re-emergence of polio, and outbreaks of measles, whooping cough and diphtheria.

Despite the benefits and logic, vaccines are not provided to the children of non-citizens. While the public health benefits are huge, concerns on providing healthcare to non-citizens mainly run along the lines of national security concerns and scarce healthcare budgets. 

Governments do not like to be perceived as encouraging irregular immigration by providing subsidised healthcare to non-citizens. Also, policymakers question the rationale of spending scarce healthcare resources on non-taxpayers.

We applaud the decision by the director-general of health in working with Unicef, the WHO and the Philippines government in providing vaccines to non-citizen children. We hope that this short-term emergency measure is followed by long-term systems-building measures.

To that end, we propose a stepwise approach to providing essential healthcare to non-citizens in Malaysia, to be considered beyond the immediate necessity of interventions in Sabah. 

These steps should be undertaken in concert with the ministries of Home Affairs (including police and immigration), Defense (including the coast guard), Foreign Affairs (in bilateral and Asean settings), and Health.

Firstly, we propose allowing all mothers and children access to immunisation programmes, maternal and childcare services and hospital delivery, provided in public health facilities. 

In addition to reducing the incidence of vaccine-preventable diseases, this move would reduce maternal and child mortality rates. Even though Malaysia has low national mortality rates, the country does not report non-citizen deaths to the WHO. 

Children do not exist separately from their mothers, and there are humanitarian, ethical, religious and practical considerations of providing healthcare to mothers. This must be done in a non-criminalised fashion.

Secondly, we propose providing health insurance for all non-citizens including undocumented migrants. We should look to the example of Thailand, the only Asean country and one of a few globally to allow undocumented migrants to opt-into national health insurance schemes. Thailand allows non-citizens to purchase health insurance with the simultaneous application for temporary identity documents and work permits, as a part of a measure to regularise undocumented migrants.

Finally, decoupling healthcare from immigration is a crucial step. Currently, non-citizens are deterred by fear and the financial cost from seeking care at public healthcare facilities, therefore avoiding all but the most urgent of healthcare. 

Healthcare professionals are bound by the Hippocratic Oath to do no harm and are thus conflicted by requirements to report their patients. A public debate must ensue to resolve this impasse.

We are aware that issues of national sovereignty, the justice of public services to non-taxpayers and geopolitics make the issue of non-citizens’ health very fraught. However, the case in Sabah has brought these “invisible problems” very much to the surface. As a society, we owe it to our children to have these uncomfortable but crucial conversations so that we can protect the health of everyone.

The writers are public health physicians.

The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.